Improving Management of Deterioration in Acute Care Settings

The current discussion highlights the importance of effective management of deteriorating patients with sepsis, emphasizing the need for accurate vital sign recording and proper communication. It is crucial to train nurses in acute care settings to develop adequate skills and competencies for recording vital signs effectively and determining the level of risk. Additionally, nursing professionals should focus on using the SBAR communication model to share information efficiently. The rapid response system can play a significant role in managing deterioration effectively.

1
Early Recognition of a Deteriorating Patient

2
Table of Contents
Introduction......................................................................................................................................3
Pathophysiology..............................................................................................................................3
Case Studies.....................................................................................................................................4
Influences on Clinical Decision-Making.....................................................................................5
National Standards...................................................................................................................5
Professional Influences............................................................................................................7
Legal, ethical and practical considerations on early recognition of deterioration...........................8
Legal Influences.......................................................................................................................8
Ethical Influences....................................................................................................................9
Evidence to be Considered......................................................................................................9
Recommendations..........................................................................................................................10
Conclusion.....................................................................................................................................11
References......................................................................................................................................12

3
Introduction
Taking care of deteriorating patients is crucial for obtaining better healthcare outcomes. The role
of nurses is crucial in this case. If the signs of deterioration are detected at an early stage,
managing the situation becomes easier. The nurses also play a crucial role in prioritizing the
activities in emergency situations (Flenady et al., 2016). As an effect, taking the right course of
action becomes easier when the nurses become able to prioritize the tasks appropriately. The risk
of deterioration is quite high in the case of Sepsis (Gauer, 2013). In such cases, taking rapid
action is necessary to improve the health condition (Godin et al., 2015). The researcher takes
care of the patients with Sepsis. The patients who are dealt with by the nurse need the care of
level 0 and level 1. Such patients are at higher risk of deterioration. However, the potential
adverse effects on health can be prevented by taking the clinical decision at the right time.
However, clinical decision making for deteriorating patients is influenced by a number of
factors. Nursing Ethics is one of the factors which impact on the decision making of the
professionals. The decisions are also influenced by the evidence, national and professional
standards. In this essay, the factors influencing the clinical decision-making of the deteriorating
patients of level 0 and 1 with Sepsis are discussed. The role of evidence at the time of decision
making is also considered in this essay.
Pathophysiology
Sepsis is described as a clinical syndrome (Brent, 2017). It is caused by the actions of
immune systems damage tissues in the body while coping with an infection (World Health
Organisation, 2018). Sepsis also causes Sepsis shock if not detected and managed on time
(Casey,2016). Sepsis with shock creates a life-threatening condition. It causes by low blood

4
pressure even when fluid replacement remains adequate. Sepsis with shock also causes organ
dysfunction or failure. Sepsis can be fatal for the people of all ages. Sepsis can be caused due to
any pathogen (Daniels. and Nutbeam, 2017). However, the patients with resistant pathogens are
at higher mortality risk (World Health Organisation, 2018).
Case Studies
In case of the patient Q, the NEWS2 score is 6. The patient is found with confusion and soaked
in smelly urine. The high NEWS2 score It indicates high risk of mortality. The patient was
treated after four hours of contacting the General Practitioner. In the case of high mortality risk,
waiting for long time might have adverse effect on the patient’s health. The patient was short of
breathe also. The patient C was initially treated with medicines and refused to visit the hospital
but after some time, she was suspected to be dehydrated. So, intravenous fluid was needed.
Under this circumstances, the patient was taken to the hospital. The nurse communicated about
the suspected Sepsis of the patient using SBAR framework.
The patient D has lower risk. However, in this case also prompt action was taken to avoid
further degradation. The patient was alert. After initial inspection, it appeared that the patient
have Cellulites. However, the samples were sent to culture. The patient was given oral
antibiotics. He was also monitored at home for 24 hours.
Taking rapid action is necessary to manage Sepsis effectively. In this case also, the actions were
taken rapidly.

5
Influences on Clinical Decision-Making
National Standards
NHS has developed different quality standards for taking a clinical decision for deteriorating
patients. NHS also focuses on using evidence based practices to manage Sepsis (NHS, 2017).
Therefore, diagnosing the early signs of deterioration is crucial for improving the health of the
patients (Levy et al., 2018). The quality standard of NHS needs to be followed at the time of
clinical decision making of the patients with Sepsis.
The patients who are suspected to have Sepsis need to be assessed with the help of a structured
observation of the vital signs (Wang et al., 2014). The set of observations is used to determine
the risk of organ failure and death. The individuals who are suspected to have Sepsis need
assessment for determining the need for urgent intervention (Jevon and Ewens, 2012). The
structured observation should ensure that the patients should be provided with appropriate
treatment in a timely manner (Nagalingam, 2018). In both the cases, the patients were suspected
to have sepsis. So, the professionals focused on examining them using ABCDE framework and
NEWS 2 score. It makes the process accurate.
Assessing the vital signs is crucial to determine the risk (Ljunggren et al., 2016; Van Noekerk et
al., 2017).The NEWS2 (National Early Warning Score) framework needs to be used at the time
of physical assessment. The NEWS2 assesses the health of the patient on the basis of several
parameters such as— oxygen saturation, respiration rate, systolic blood pressure, level of
consciousness or confusion, temperature and pulse rate. The scores are collected for each
parameter and the deviation from the normal level is measured. Use of the NEWS2 framework
gives an idea on the extent to which the patient is at risk.

6
The quality statement 2 indicates that the patients who are admitted in the acute hospital settings
and suspected with sepsis should be treated with the first dose of intravenous antibiotics if they
show at least one criteria of acute health risk and illness. A clinician should also review the
patient within 1 hour of identifying the risk.
The third quality statement indicates that patients with suspected Sepsis require restoring the
cardiovascular activity with intravenous fluid bolus within an hour of risk being determined. Use
of intravenous fluids for early intervention is useful for managing sepsis. The intravenous fluids
are able to reverse the septic shock. Such fluids also restore cardiovascular stability. Therefore, it
is highly effective for individuals who are experiencing a high risk of death or severe illness. The
intravenous fluids are also able to improve the delivery of oxygen to the organs. As an effect, the
risk of poor tissue perfusion and long-term disability is addressed.
The quality standard four indicates that the patients who are suspected to have Sepsis and
admitted in the acute hospital settings should be monitored after the intervention with antibiotics
(World Health Organization, 2017). In both the cases, oral antibiotics were given initially. They
need to be seen by a consultant the condition does not improve after an hour of initial treatment.
Septic shock increases the risk of death (Parkes, 2011; Pittet and Allegranzi,2017). So, the views
of the specialists are important for the people who do not show any sign of improvement. Under
these circumstances, considering the views of the specialists is necessary.
As indicated by quality standard five aims at improving the health of the people who are at the
lower risk of illness and death. This quality standard aims at identifying the symptoms,
monitoring and accessing medical care. The risk of Sepsis cannot be eliminated for the

7
individuals who have a lower risk of death and illness. Monitoring the symptoms and increasing
access to healthcare services is necessary to avoid degradation.
Professional Influences
Professional standards influence the decision making of nursing professionals while dealing with
deteriorating patients in acute care settings. ABCDE is a framework that helps the nursing
professionals to get a holistic idea on the condition of the deteriorating patients and take actions
accordingly.
ABCDE Framework
ABCDE framework is based on looking at the patient, listening to the patient and feeling the
patient. The systematic assessment of the deteriorating patients done in five stages. The first
stage deals with checking the airway of the patient. In the second stage, the breathing of the
patients is assessed (Resuscitation Council, 2014). The third stage deals with checking the
circulation in the patient. In the fourth stage, the disability of the patient is determined. The
disability is determined using the AVPU scale. The AVPU scale identifies the level of alertness
of the patient, responses to the voice and pain and the unresponsive status (Resuscitation
Council, 2014). The fifth and last stage focuses on examining the patient and assessing the
condition on the basis of the charts and patient history.
Sepsis causes symptoms such as confusion and drowsiness (Rhodes et al., 2016). Use of ABCDE
framework is effective as it helps the professionals to identify the level of disability. Use of the
framework is also useful to identify the other symptoms of sepsis such as Tachypnoea and
Tachycardia by assessing the airways and breathing. It indicates that the ABCDE framework is
effective to detect deteriorating sepsis at the early stage. The needs of the level 0 patients can be

8
fulfilled in the normal wards of the acute care setting whereas the level 1 patient has the risk of
deterioration. Using the ABCDE framework, the necessity of transferring the patients to the
critical care unit can be determined early. It provides better health outcomes. In the case of
patient C and D, the ABCDE framework was followed which indicates that the assessment was
accurate.
SBAR tool is useful to make the communications in the second and third stage more effective.
While using SBAR approach of communication, the nurses firstly require sharing their own
identity, the key concern and the patient’s identity. In the next stage, the nurses share the
intervention which has been undertaken so far and the recommendations which need to be done
to prevent further deterioration. In this case, SBAR was used in the case of patient C. Use of the
tool helped the professional to convey the concerns clearly and get prompt help.
Legal, ethical and practical considerations on early recognition of deterioration
Legal Influences
The rapid response system is crucial to deal with deteriorating patients in acute care settings.
The rapid response system is closely associated with the NEWS and SBAR (Situation,
Background, Assessment and Recommendation) communication tool. While dealing with the
patients with the deteriorating condition, the rapid response system to manage and prevent
further deterioration in three stages. The first stage deals with recording the vital signs as the
deterioration can be predicted on the basis of these signs. The second stage deals with
recognizing the condition of the patient. The deterioration in the condition of the patients causes
changes in the vital signs. Any change in the vital sign can be identified using the NEWS
approach. qSOFA ( Quick Sequential Sepsis-Related Organ Failure Assessment) is another

9
approach that can be used to assess mortality risk for patients with Sepsis. qSOFA assesses the
mental status, systolic blood pressure and respiration rate of the patients and allocates scores
accordingly. Based on the scores, the risk of mortality can be determined. However, upon
recognizing the condition of the patient, the nursing professionals need to take actions as per the
hospital expertise and the protocols. The third stage of the response system is responding to the
condition. The immediate treatment should be started to prevent deterioration in the condition of
the patient. The nursing professionals might ask for help in the second and third stage as per the
requirement.
Ethical Influences
The nursing practices are influenced by the competence of the professionals, their attitude to the
care and courage to take initiatives. The nursing professionals in acute care settings require being
competent enough to make the right choice. In other words, nursing professionals should have
adequate technical and clinical knowledge to identify the needs of the patients and take the
appropriate actions. The nursing professionals also require delivering the care in such a way so
that the lives of the deteriorating patients improve. Finally, courage helps nursing professionals
to express their concerns regarding the patients and take timely actions.
Evidence to be Considered
There are a number of evidence which has indicated that the use of the Rapid Response System
(RRS) is useful to obtain better health outcomes. RRS is beneficial to reduce the rate of cardiac
arrest and mortality. It is evident that the rapid response system is necessary to manage the
deteriorating condition of the patients and improve the outcomes. The use of a Rapid Response
System is useful for improving the vital sign monitoring practices among the nurses. However, in
many cases, the protocol is not followed. The lack of adherence to the protocols reduces the

10
effectiveness of the deterioration management process (Smith and Meyfroid,2017). Skill,
training and experiences enable the nurses to offer quality care. Due to the lack of skill and
experiences, the nurses fail to record the vital signs accurately and allocate scores to the patients.
As an effect, determining the level of the risk to the patients also become ineffective. A
significant number of deaths in the UK occurred due to deterioration mismanagement, failure of
prevention and oversight. It indicates that the nursing professionals in the UK require improving
the management techniques while dealing with deterioration, checking and determining the
condition of the patients. Nursing professionals also need to prevent deterioration techniques.
Ineffective communication between the doctors and the nurses is another technique that reduces
the usefulness of the rapid response system.
Recommendations
The following recommendations are effective to obtain quality outcomes for the level of 0-1
patients in the acute care settings—
Implementation of Rapid response System— The Rapid Response System should be
implemented in the care setting at all levels. It is especially important for the patients of level 1
as they have a higher risk of deterioration. The services should be provided faster to reduce the
risk.
Adherence to protocol— Non-adherence to the protocol is one of the key reasons behind the
mismanagement of deterioration and the associated deaths. So, the nursing professionals should
be encouraged to adhere to the protocols to improve management of the deterioration.

11
Training and Education-- The lack of expertise for recording the vital signs and the early
warning signs scoring is another cause behind inefficient management of deterioration. The
nurses in acute care settings should be trained so that they develop adequate skills and
competencies to record the vital signs effectively and determine the level of risk. The nurses
should also know to use the SBAR communication model to share information effectively.
Conclusion
The current discussion indicates that deteriorating patients can be managed effectively with the
help of the rapid response system. The discussion also indicates that nursing professionals should
focus on recording the vital signs accurately and communicating in a proper manner to manage
the deterioration.

12
References
Brent, A. (2017) Sepsis. Medicine, 45 (10), pp. 649-653. doi: 10.1016/j.mpmed.2017.07.010
Casey, G. (2016) Could this be sepsis? Nursing New Zealand, 22 (7), pp. 20-24.
Daniels, R. and Nutbeam, T. (eds) (2017) The sepsis manuel: responsible management of sepsis,
severe infection and antimicrobial stewardship. 4th Edition. Birmingham: The UK Sepsis
Trust.
Flenady, T., Dwyer, T. and Applegarth, J. (2016) Rationalising transgression: A grounded theory
explaining how emergency department registered nurses rationalise erroneous behavior.
Grounded Theory Review, 2 (15).
Gauer, R. (2013) Early recognition and management of sepsis in adults: the first six hours. Am
Fam Physician, 88 (1), pp. 44-53.
Godin, M., Murray. P. and Mehta, R.L. (2015) Clinical approach to the patient with AKI and
sepsis. Seminars in Nephrology, 35 (1), pp. 12-22. doi:
10.1016/j.semnephrol.2015.01.003
Jevon, P. and Ewens, B. (2012) Monitoring the Critically Ill Patient. 3rd Edition. Chicester:
Blackwell.
Levy, M.M., and Evans, L.E., and Rhodes, A. (2018) The surviving sepsis campaign bundle:
2018 update. Critical Care Medicine, 46 (6), doi: 10.1097/ccm.0000000000003119
Ljunggren, M., Castren, M., Nordberg, M., and Kurland, L. (2016) The association between vital
signs and mortality in a retrospective cohort study of an unselected emergency

13
department population. Scandinavian Journal of Trauma, Resuscitation and Emergency
Medicine, 24 (1), p. 21. doi:10.1186/s13049-016-0213-8
Nagalingam, K. (2018) Understanding Sepsis. British Journal of Nursing, 27 (20), doi:
10.12968/bjon.2018.27.20.1168
NHS England (2017) Sepsis guidance implementation advice for adults. Available from
https://www.england.nhs.uk/wp-content/uploads/2017/09/sepsis-guidance-
implementation-advice-for-adults.pdf
Parkes, R. (2011) Rate of Respiration: the forgotten vital sign. Emergency Nurse, 19 (2), pp. 12-
18.
Pittet, D., and Allegranzi, B. (2017) Preventing sepsis in healthcare – 200 years after the birth of
Ignaz Semmelweis. Eurosurveillance, 23 (18).
Resuscitation Council (UK) (2014) Guidelines and guidance. The ABCDE approach. Underlying
principles. London: Resuscitation Council (UK).
Rhodes, A., Evans, L.E., Alhazzani, W., Levy, M.M., Antonelli, M., Ferrer, R., Kumar, A.,
Sevransky, J.E., Sprung, C.L., Nunnally, M.E., Rochwerg, B., Rubenfeld, G.D., Angus,
D.C., Annane, D., Beale, R.J., Bellinghan, G.J., Bernard, G.R., Chiche, J.D.,
Coopersmith, C., De Backer, D.P. French, C.J., Fujishima, S., Gerlach, H., Hidalgo, J.L.,
Hollenberg, S.M., Jones, A.E., Karnad, D.R., Kleinpell, R.M., Koh, Y., Lisboa, T.C.,
Machado, F.R., Marini, J.J., Marshall, J.C., Mazuski, J.E., McIntyre, L.A., McLean, A.S.,
Mehta, S., Moreno, R.P., Myburgh, J., Navalesi, P., Nishida, O., Osborn, T.M, Perner,
A., Plunkett, C.M., Ranieri, M., Schorr, C.A., Seckel, M.A., Seymour, C.W., Shieh, L.,

14
Shukri, K.A., Simpson, S.Q., Singer, M., Thompson, B., Townsend, S.R., Van der Poll,
T., Vincent, J.L., Wiersinga, W.J., Zimmerman, K.L. and Dellinger, R.P. (2017)
Surviving sepsis campaign: International Guidelines for management of sepsis and septic
shock: 2016. Intensive Care Medicine, 43, pp. 304-377. doi: 10.1007/s00134-017-4683-6
Smith, M., and Meyfroid, G. (2017) Critical Illness: the brain is always in the line of fire.
Intensive Care Medicine, 43 (6), pp. 870-873.
Van Noekerk, G., Davis, T., and Englebrecht, A.M. (2017) Hyperglycaemia in critically ill
patients: the immune system’s sweet tooth. Critical Care, 21 (202), doi: 10.1186/s13054-
017-1775-1
Wang, D., Yin, Y., and Yao, Y. (2014) Advances in sepsis-associated liver dysfunction. Burns &
Trauma, 2 (3), pp. 97-105. doi: 10.4103/2321-3868.132689
World Health Organisation (WHO) (2017) Improving the prevention, diagnosis and clinical
management of sepsis. Available from
http://apps.who.int/gb/ebwha/pdf_files/WHA70/A70_R7-en.pdf?ua=1&ua=1
World Health Organisation (WHO) (2018) Sepsis, Key facts. Available from
https://www.who.int/news-room/fact-sheets/detail/sepsis